2005 Japanese Society for Dialysis Therapy Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis

Abstract

The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, 'Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis'. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access-related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)-related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long-term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2-3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

Predictors of Initiation for Predialysis Arteriovenous Fistula

“…This predictive model seems to be reasonably accurate, because the corresponding likelihoods of starting hemodialysis after AVF creation in this study were 74% (182 of 246) and 81% (118 of 145) in patients with eGFRs,20 and ,15 ml/min per 1.73 m 2 , respectively. Vascular access guidelines promulgated by different national societies have proposed various eGFR thresholds for referral of a patient with CKD to the surgeon for access creation (10)(11)(12). Unfortunately, these guidelines are opinion based, and their validity has not been subjected to empirical evaluation.…”

“…In comparison, the Canadian Society of Nephrology recommends placement of the AVF when eGFR is between 15 and 20 ml/min per 1.73 m 2 (10), the Japanese Society for Dialysis Therapy recommends AVF placement when the creatinine clearance is between 10 and 20 ml/min or serum creatinine is between 6 and 8 mg/dl (11), and the European Best Practices Guidelines recommend vascular access placement when the eGFR reaches ,30 ml/min per 1.73 m 2 (12). Because these national guidelines are not on the basis of clinical evidence and because none of them incorporate clinical patient characteristics, the optimal timing of predialysis vascular access placement remains unknown.…”

Outcome of Hemodialysis Patients Who Had Failed Peritoneal Dialysis

“…Our observation reveals an important area for further quality improvement in patient care. Experience in Japan shows that careful vascular access planning and early arrangement of fistula surgery ensure an excellent rate of successful fistula usage, even in an ethnic group with small body build [22]. …”

Successful initiation and maintenance of hemodialysis in an adult patient with complete transposition of the great arteries

“…On the other hand, HD has the drawback of rapid ultrafiltration in a relatively short time, leading to unstable hemodynamics. In addition, HD in patients with arteriovenous fistula inevitably provokes increased cardiac output, which could lead to heart failure [12]. However, HD with superficially transpositioned artery may avoid heart burden because HD has the benefit of limiting the heart burden to the period of HD.…”